Damaging NHS disputes hindering progress on productivity, finds survey

By Integrated Care Journal

Trusts making progress on NHS targets and taking steps to boost productivity but concern mounting about staff morale and burnout as operational pressures take their toll.

Ongoing industrial action presents a major operational and financial challenge for NHS trusts, and is hindering all trusts’ ability to recover productivity, according to a new survey carried out NHS Providers. It highlights the scale of the task ahead for the NHS, as it simultaneously grapples with increasing numbers of patients with complex conditions staying in hospital for longer, emergency care pressures and limited bed capacity, exacerbated by the crisis-hit social care sector.

Trusts across hospital, community, mental health and ambulance services have made significant early progress towards meeting care backlogs for urgent and emergency care, cancer tests, long waits and diagnostic services as they strive to deliver better outcomes for patients, say NHS Providers.

They have introduced a range of measures to boost productivity in the NHS – delivering more care with existing resources – including targeted initiatives to improve staff health, wellbeing and retention alongside efforts to help discharge patients faster and adapting their buildings to treat more patients.

But trusts are now warning that eight consecutive months of industrial action across the NHS are taking their toll on efforts to cut waiting lists, with more than 651,000 routine procedures and appointments rescheduled so far and many tens of thousands more likely to be delayed as the health service faces back-to-back walkouts by junior doctors, consultants and radiographers in the coming days.

“Increasingly hard to improve productivity”

The new survey by NHS Providers, Stretched to the limit: tackling the NHS productivity challenge, outlines the scale and complexity of the challenge ahead, particularly as trust leaders count the cost of industrial action given the disruption to planned care, and increasing costs due to agency spend and the impact of consultant rate cards.

The Chief Executive of NHS Providers, Sir Julian Hartley, said: “Leaders and staff are working flat-out to cut waiting lists and to see patients as quickly as possible in the face of major obstacles.

“With waiting lists at a record high, trusts are keenly aware of the need to carry out more operations, treatments and scans. They are doing everything they can to see more patients more quickly and to deliver better quality care, including introducing virtual wards and new initiatives to speed up hospital discharge and offer more care at home.

“However, it is increasingly hard to improve productivity because of staff burnout, high turnover, vacancies, a rising number of patients with more complex conditions, stretched community and social care capacity, and fewer hospital beds per person than comparable countries.

Trusts are also warning that it will be very difficult to deliver the government’s overall demands in terms of performance while delivering unprecedented efficiencies, seeking to protect quality of care for patients.

The survey finds that:

Almost nine in ten (89 per cent) trust leaders said the scale of the efficiency task is more challenging than it was last year.
Almost three in four (73 per cent) did not think they had access to sufficient capital funding over 2023/24 to cover the costs of vital repairs to buildings and equipment.
Nearly two thirds (61 per cent) were not confident that they and their system partners would hit targets to reduce long waits for mental health care.
Fewer than half (43 per cent) expect to meet an interim recovery target of 76 per cent of A&E attendances to be seen within four hours during 2023/24.

The findings reveal widespread worry among trusts about having to deliver more for less as budgets, staff and resources are stretched to the limit, leaving trust leaders facing increasingly difficult dilemmas about how to sustain services in the future.

Despite an overall increase in workforce numbers and the welcome promise of more staff in the future through the new long-term workforce plan, rising concerns about staff morale and burnout also continue to play heavily on trust leaders’ minds. They are contending with 112,000 vacancies across the health service in England with staffing numbers and skill mix failing to keep pace with growing and changing demand.

This is piling on the pressure, with trust leaders identifying discharge delays, relentless demand on emergency care, a lack of investment in social care and a dependency on agency staff as the biggest barriers to returning to pre-pandemic levels of productivity.

They are clear that capital investment in the NHS estate is also key to boosting productivity. This would allow trusts to expand bed capacity and community provision, deliver digital transformation, bear down on care backlogs and eliminate the persistent inefficiencies created by creaking buildings and equipment.

But with the NHS capital maintenance backlog now exceeding £10bn, and only a handful of trusts benefitting from much-needed investment through the New Hospital Programme, a great many more need urgent major capital investment to overhaul their ageing estates to achieve better – and safer – outcomes for patients.

Sir Julian Harley added: “Industrial action also poses a significant financial risk to trusts, given the disruption to planned care, and increasing costs due to agency spend and the impact of consultant rate cards.

“The new long-term workforce plan with its focus on recruitment, training and retention could finally put the NHS workforce on a sustainable footing if commitments are made to keep it updated and funded. But the benefits of that plan can only be reaped with a wider focus on productivity and its enablers, many of which we explore in this report, such as investment in management capacity and capital.

“If we are to ramp up productivity across the NHS, we need a step change in capital investment to provide more beds, more community care, a digital revolution, a safe and comfortable therapeutic environment, and appropriate support for social care.”

Digital appointments could save the NHS £167 million per year: report

By Integrated Care Journal

Opening new digital pathways could free up capacity and help reduce NHS elective care backlog

Giving patients greater digital control over their hospital appointments could avoid 1.6 million unnecessary appointments and create a national annual system saving of £167 million, according to a new report commissioned by, patient engagement platform supplier, DrDoctor.

The report, commissioned by DrDoctor, a patient engagement platform supplier, and conducted by health economics consultancy Edge Health, analysed NHS outpatient appointment data. It suggests that allowing patients to request appointments using Patient Initiated New Appointments (PINAs) and Patient Initiated Follow-Ups (PIFUs) could significantly help to reduce the backlog in NHS elective care.

Reducing outpatient follow-up appointments

The data reveals that putting patients on digitised PIFU pathways for both high-volume, low complexity conditions and smaller volume, higher-complexity conditions could lead to at least 1.18 fewer outpatient follow-up appointments per patient. If implemented nationally, this could free up the waiting list for 1.4 million hospital appointments, creating capacity for more patients to be seen, and saving the NHS £167.2 million per year.

The report finds that the average time between the first appointment and follow-up appointments is also longer when patients are on a digital PIFU pathway. This indicates that when patients can initiate follow-up appointments themselves, they are likely to wait longer, which in turn creates more capacity for new patients to be seen, reducing waiting times further.

Supporting the elective backlog recovery

Edge Health examined the use of DrDoctor’s solutions at two of its customer sites, including PIFU and PINA tools at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in their physiotherapy services. The time and cost savings from more than 50 million outpatient appointments were applied to a national rollout to calculate the overall impact in the NHS.

The report finds that patients with mild symptoms for low complexity conditions may not need a first appointment at all. Using a digital PINA pathway to address this could reduce the number of people waiting for hospital appointments by more than 210,000, freeing up appointments for patients who need clinical care.

Tom Whicher, CEO at DrDoctor, welcomed the research findings and said: “This report demonstrates much-needed real-world evidence on the benefits of PINA and PIFU at scale. Given that the national target for 5 per cent of outpatient attendances using digital PIFU was recently dropped, the report should give confidence to providers on how these processes, enabled by digital tools, play a vital role in tackling the backlog and creating efficiency savings.”

GSTT has been using DrDoctor’s PIFU tool for musculoskeletal and hand therapy services since January 2022. The report found that more than 70 per cent of physiotherapy patients on a PIFU pathway chose not to return for a second appointment, compared to 44 per cent of non-PIFU patients. A greater number of PIFU patients also chose to request follow-up appointments later than those not on the PIFU pathway (84 per cent had it in 120 days or under vs 88 per cent in 90 days or under).

The report also finds that PIFU led to many patients requiring fewer outpatient appointments, creating capacity to reallocate these appointments to patients with more complex care needs who need to be seen more frequently. The ability to reallocate these appointments has created capacity for an additional 9,268 patients, at the value of £719,476 per year.

Rashida Pickford, Consultant Physiotherapist, GSTT, was involved in the research and said: “The analysis shows the benefits of using technology to give patients more control over their appointments. Avoiding clinically unnecessary appointments means we can provide a better patient experience and free up much-needed time for clinical and administrative staff.”

The report also concluded that from the patient’s perspective, demographic factors such as age, do not limit engagement with digital PIFU pathways. Tom Whicher added: “Often there are concerns about digitisation because it isn’t accessible for everyone. And whilst that can be true, this report confirms that it’s often an exception rather than the rule.”

DrDoctor helps manage around 25 per cent of NHS outpatient booking activity and provides digital PIFU, PINA and patient engagement services in over 45 healthcare organisations.

PPP’s Population Health Management Collaboration Framework

By Mary Brown

A new framework from PPP enables ICSs and business to assess and measure the progress of their collaboration on population health management.

Over the first half of 2023, PPP ran a series of roundtables for our Population Health in Business series, to analyse and explore the impact of business on the health of local populations, and explore how this impact can be leveraged to deliver benefits to businesses, workforces and communities. As the report highlights, ensuring that local business activity is sensitive and responsive to local health challenges requires close collaboration between business and local authority leaders. This collaboration, ideally, should occur within the framework of the integrated care partnership (ICP).

ICPs are intended to allow ICS leaders to “bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population”, as well as spearheading the integrated care strategy for a given system. Each ICS can decide which partners are included in the ICP, however suggested partners include local Health and Wellbeing Boards (HWBs), social care providers and members of the VCSE sector.

As conveners of local health-relevant organisations beyond the NHS, ICPs have the potential to rebalance the focus of health and care away from acute hospital settings and towards the broader health needs and goals of communities. This will empower organisations not traditionally involved in health-related decisions to make more active contributions to public health outcomes. Businesses have the potential to serve as partners in the delivery of a health inequalities strategy given their impact on their workforce and surrounding communities, and grow the impact of assessments such as the JSNAs already produced by HWBs.

The PPP PHM Collaboration Framework – part 1 of 2 (click to enlarge)

Joining up business and public health

By bridging the gap between public services and local industry, ICPs can support and monitor actions taken by businesses to create healthy workplaces and support employee health, assisting in setting priorities and objectives and advising on health and wellbeing issues. ICPs can also serve as forums of communication and alignment between ICSs, businesses and local health-relevant organisations, enabling businesses to contribute more effectively to community health.

ICPs could also play a central role in enabling better public-private data exchange, which will be crucial in determining the quality and impact of PHM insights. As a broad alliance of partners, ICPs can provide a forum through which businesses and local authorities can improve the accessibility and availability of data. While the needs and capabilities of businesses with regards to data usage vary significantly within an ICS region, the development of PHM strategies is ultimately a process that caters to the needs of a specific population reflected in health-relevant data collected and held by businesses.

The full Population Health in Business report can be accessed here.

Where businesses are able to share insights and collaborate to improve health outcomes within the same population (both with one another and with local authorities), there is a significantly greater opportunity for mutual needs to avail themselves – thereby laying the groundwork for more effective collaboration. The blueprints for such a collaboration can then be shared between ICSs and with central authorities such as DHSC, and local government including the Local Government Association and the Department for Levelling Up, Housing and Communities, to facilitate their development of data standards as recommended by the Hewitt Review.

However, though the report suggests that businesses should collaborate with one another and local authorities, using the ICP as a connecting forum, it must be recognised that many of these partnerships remain underdeveloped and that their progress is likely to be asymmetric. It is therefore necessary that businesses take an active role in assessing the strength of their own actions on health inequalities and their collaborations with local authorities.

PPP’s PHM Collaboration Framework – part 2 of 2 (click to enlarge)

A framework for collaboration

There are ongoing concerns within ICSs around the challenges of balancing the unique local needs and priorities of regions with national standards. In order for all ICPs to partner with local businesses in achieving improved regional health, collaboration and data sharing frameworks should be utilised to ensure consistent goals and progress across regions with different priorities, while avoiding duplication and so as not to discourage inter-ICS collaboration.

In order to support businesses and ICPs to implement the findings and recommendations from the series, PPP has crafted a suggested framework for ICS and businesses to collaborate and measure progress.

The framework is intended to compliment other matrices, such as the Leeds City Council Business Progression Framework, the JRF Business Progression Framework (both assembled by Les Newby and Nicky Denison), and the ICS Maturity Matrix (created by Cathy Elliott). These matrices provide examples of best practice and rough guides for organisations to evaluate their own progress as health-enhancing institutions. As such, the PPP PHM Collaboration Framework is intended to guide businesses to evaluate their own progress towards partnering with local authorities and interacting against local health systems to develop robust preventative healthcare and target causes of ill health.

The full Population Health in Business report can be accessed here.

Edge Health, News, Thought Leadership July 11, 2023

Rethinking cancer care: a system strategy for improved outcomes

By Lucia De Santis and George Batchelor

Boosting early detection and reducing backlogs through data-backed, collaborative initiatives will be crucial to addressing the deteriorating state of cancer care in the UK, write Edge Health’s Lucia De Santis and George Batchelor.

In the battle against cancer, the UK is grappling with alarming statistics, with outcomes for colon, lung and pancreatic cancers being particularly sobering. According to the Comparator report on cancer in Europe 2019, the UK was last out of all Western European nations for 5-year survival of colon cancer, as well as among International Cancer Benchmarking Partnership (ICBP) jurisdiction countries (Figure 1).

Figure 1: Age-standardised incidence, mortality rates and 5-year net survival for Colon cancer. Arnold M, Rutherford M, Lam F, Bray F, Ervik M, Soerjomataram I (2019). ICBP SURVMARK-2 online tool: International Cancer Survival Benchmarking. Lyon, France: International Agency for Research on Cancer. Available from: http://gco.iarc.fr/survival/survmark, accessed [08/06/2023]. (Click to enlarge)

The complex factors behind the UK’s cancer outcomes

Understanding the root of this crisis is not straightforward, as many intertwined factors play roles, from cultural attitudes affecting help-seeking behaviours to underinvestment in critical medical resources. As a doctor in a busy acute trust, I could not grasp why one of my patients only presented to hospital long after his skin tone had turned an unmistakable dark shade of yellow, a tale-telling sign of his late-stage lymphoma. On the other hand, as of 2021, the NHS operated with around 63 decade-old LINACs (essential cancer treatment machines), and the UK has the lowest number of PET-CT scanners per 100,000 people among International Cancer Benchmarking Partnership countries.

The UK’s uphill struggle is deep-seated, with it having the worst cancer survival rates in the EU as far back as 1995. NHS’s low spending on cancer treatments and restricted access to cancer medicines for patients have been contributing factors.

Turning the tide: a dual-pronged strategy

Despite the complexity, there are attainable starting points for improvements: boosting early detection through the two-week-wait (2WW) referral pathway and ensuring prompt diagnosis and treatment through collaborative approaches that have proven successful in other countries.

Front one: boosting early detection

Data shows that cancers identified via a 2WW referral are often diagnosed earlier, and result in fewer diagnoses during emergency admissions, with implications for survival.

Analysis on stage at diagnosis performed by Cancer Research UK (Figure 2) demonstrates this clearly, with 30 per cent of cancers detected via 2WW referral being at Stage 1, versus just 8 per cent of cancers detected through an emergency presentation to hospital.

Figure 2: Proportion of cancers by stage at diagnosis by route of detection. Source: Cancer Research UK Early Diagnosis data, accessed June 2023. (Click to enlarge)

However, across England, there is a glaring disparity in cancer detection rates – that is, the number of confirmed cancers that are detected via an urgent suspected cancer referral (2WW). This is intimately related to the overall volume of 2WW referrals (Figure 3), where higher figures are associated with a higher detection rate.

Patients whose practices have a lower threshold to refer under the 2WW programme fare much higher chances to have cancer detected via this route and as shown above, at an earlier stage. This, again, has implications for treatment and survival.

The national disparity between these practices not only means that average figures for cancer outcomes are affected by differing primary care strategies, but also that there are wide inequalities of care across the nation.

Cancer alliances and primary care networks can play an essential role in encouraging practices to revisit their referral behaviours. This effort can help reduce healthcare inequalities and potentially save lives by identifying and treating cancer earlier. Understanding what drives referral rates and promoting effective referral practices can make the difference between a life saved and one lost, and in the end spare the much higher healthcare and societal costs associated with late-stage cancer.

Front two: tackling backlogs through collaboration

Our second strategy is to reduce backlogs through collaboration. The NHS’s diagnostic capacity is currently strained, as the steady decline in patients diagnosed within the 28-Day target since its 2021 introduction suggests.

Figure 4: Proportion of patients referred for suspected cancer who meet the 28-Day faster diagnosis standard that was introduced in 2021. (Click to enlarge)

Taking cues from countries like Denmark, which successfully improved cancer survival rates by centralising specialised care and launching data-focused initiatives, the NHS can rethink its approach. By making comprehensive cancer patient data centrally available, we can make more informed decisions, improve workflow, and direct finances more effectively.

The NHS collects extensive data on cancer patients, encompassing their entire journey from referral to treatment. The key to better cancer care is ensuring the data is available centrally to key organisations and decision-makers, such as integrated care systems and Cancer Alliance leaders, to make evidence-backed financial, workflow and population health decisions and foster collaboration.

Sharing cancer data can help speed up diagnosis and treatment for patients. For instance, by sharing a cancer patient tracking list (PTL) across multiple trusts, patients who are at risk of breaching targets can be identified early and receive timely care. This strategy can also address the shortage of diagnostic appliances or services and specialised treatment.

Figure 5: Example of how cancer alliance PTL data could be pooled to estimate breach risk scores and inform waiting lists to either allow local prioritisation or highlight mutual aid opportunities. (Click to enlarge)

The road ahead: data-driven initiatives and collaboration

The current state of cancer care in the UK calls for an urgent, systemic response. By prioritising early detection and fostering data-driven collaboration, we can significantly enhance the prognosis for the UK’s cancer patients.

Expediting early detection efforts, particularly through increased 2WW referrals, is crucial to change the narrative. These efforts, when paired with the power of collaborative and data-driven care models, can revolutionise the cancer care landscape. It’s a potent combination that can help us ensure that no matter where patients live, they can access timely and high-quality cancer care. This system-wide approach presents an opportunity not just to catch up with our European neighbours, but to potentially lead the world in effective cancer care.

All news

Why personalised care must go beyond ‘patient-centricity’

By Dr Rob Simister

Dr Rob Simister, Clinical Director for Stroke and Acute Neurology, University College London Hospitals (UCLH) NHS Foundation Trust, writes about how digital platforms can help personalise stroke care, leading to better outcomes for patients and carers.

‘Personalised care’ is a term that has become ubiquitous, and something that the NHS has been striving to achieve for some time. As an NHS consultant, I understand the aim of personalised care to be the provision of a care programme that is tailored to the specific needs of each patient, and delivers better outcomes and a better life experience.

This ambition to create a personalised recovery pathway for survivors of medical emergencies, such as stroke, is critical. Such patients will have specific patterns of injury, risk factors, treatment programmes and rates of recovery. Each patient also brings with them a specific life history, expectations and hopes for the future. We can only help individuals to recover in the best way possible if we take all these elements into account. The challenge is the delivery of this personalised care across the wider patient group, and so far, we have struggled with this.

This is where technology can make a huge difference. By creating bespoke packages of support, we can equip patients, their families and carers with information pertinent to the event and help them understand what to expect throughout their recovery journey and how to manage their health and reduce the risk of secondary stroke in the future. Critically, this can be done at scale.

Personalised information is personalised care

Annually, 15 million people worldwide suffer a stroke and it is one of the most common causes of death. There are approximately 1.3 million stroke survivors in the UK and many more family members living with the sudden, unplanned and life-changing consequences of stroke.

Stroke occurrence is associated with a number of modifiable and unmodifiable risk factors. Lifestyle choices, weight, and compliance with medications and environment factors are all potentially modifiable. However, we need to ensure that everyone has access to the right information presented in an accessible way, something which remains challenging particularly for minority groups and people who are socially disadvantaged. We need to ensure that this information takes account of unique experiences, background, spoken language and life challenges. This is essential in helping more people to understand their stroke and improve their recovery outcomes.

Filling the gap

To try to bridge this gap, I have been involved in the development of a digital platform called My Stroke Companion. This technology offers patients a visual and interactive support package of information, which is specific to their type of stroke, risk factors and treatment plans. While the information provided is designed to be as accessible and as easy to understand as possible, it crucially helps the patient to answer: why did this stroke happen to me? What does my recovery look like? How do I prevent it from happening to me again?

Accessible content is especially important in conditions such as stroke, where patients can struggle to take in information due to tiredness or fatigue, or difficulties processing information. This is even more difficult for patients who also experience language barriers or have pre-existing communication needs.

We are currently piloting My Stroke Companion with 500 patients – the first pilot of its kind to take place. Each patient has been given a personalised information prescription, which they can share with family members and carers, helping them to manage their condition. We have been really pleased to learn that, particularly in the earliest phase of recovery, some of the main beneficiaries of the support packages have been carers, who have valued the dedicated content that helps them to provide better care. This develops the idea of personalised care further – so that it is not just patient-centred, but also relevant and useful for carers and family who are also often deeply affected.

This positive impact could easily be replicated across other health conditions, such as cardiovascular disease and respiratory conditions, with development of these resources following a similar process of co-creation with patients, carers and digital specialists.

Better for patients, better for the NHS

Personalised digital support packages can also help trusts to create system efficiencies, which is especially crucial now that staff and services are so stretched. By providing information that can be accessed in the comfort of a patient’s home, it is possible for patients to have time to understand more deeply what has happened – and what will happen next. We hope this will lead to improved medication adherence, participation in therapy and in better lifestyle choices – leading to fewer recurrent events, less time in hospitals and better outcomes.

We also hope that the platform will help overstretched NHS clinicians by acting as a trusted resource for patients and carers, and so release this highly pressurised group to be more available for direct care delivery.

Digital personalised support offers an opportunity for the NHS to channel the right information to the right patients and help patients to gain more control over their condition after a life-changing health event.

Cost of living driving worsening health, finds Nuffield Health

By Gabriel Blaazer

Efforts to improve health outcomes being stifled by cost-of-living crisis, with many unable to afford simple measures to improve their physical and mental health

A new report from Nuffield Health has reaffirmed the damaging link between the high cost of living and worsening health outcomes in England. Nuffield Health’s The State of the Nation’s Health and Wellbeing in 2023 summarises the findings of Nuffield Health’s third annual Healthier Nation Index, a survey of 8,000 UK adults that asks detailed questions of all aspects of respondents’ physical and mental wellbeing.

It found that slightly more than one-third of people have experienced declining physical and mental health over the last twelve months (35.1 per cent and 33.7 per cent, respectively), and that nearly 50 per cent of people have experienced declining financial health over the same period. 63.2 per cent of respondents believed that the cost of living crisis is having a ‘negative impact’ on the nation’s health – a fact supported by an ever-growing body of research.

A central role for ICSs

On 13 June, Nuffield Health convened a roundtable discussion at the House of Commons, supported by MPs Kim Leadbeater and Dr Lisa Cameron, to explore the findings of the report. The roundtable highlighted the vital role that integrated care systems (ICSs) will have in ensuring that local population health strategies are responsive to the many factors influencing health, not least cost-of-living challenges.

The attendees of the Nuffield Health roundtable at the House of Commons (click to enlarge)

It was also noted that collaboration is crucial to effectively addressing the health impacts of the cost-of-living crisis “across multiple sectors – not just the NHS”, according to Nuffield Health’s post-event briefing. Contributors agreed that ICSs should seek to use “their convening ability… to collaborate with local anchor institutions, voluntary and community sector partners and local residents” to produce holistic solutions that address the multitude of factors driving poor physical and mental health.

An example of local solutions that can promote good health is the local prioritisation of building healthy environments. The need for these spaces can be best understood at neighbourhood and place level, and this insight can be turned into action through integrated care partnership strategies and collaboration with local partners, including local authorities. Participants in the roundtable identified that individual behavioural changes will only go so far, and that policies that ignore the contextual environment in which people live and work are bound to be limited in their effectiveness.

Leadership on prevention

While the key role of ICSs was discussed, it was also acknowledged that leadership around the prevention of ill health must come at the national level, with accountability shared across all government departments. It was emphasised that the most impactful preventative measures are best driven at the local level, so the role of national government should be that of an enabler for localised action, “empowering and supporting residents to be engaged in solutions, from inception to delivery”.

At the same time, greater clarity around terminology and the ultimate objectives of prevention are required, which can be instigated at a national level. Helping the population to understand how vital prevention is, and will be, for the sustainability of the healthcare system, will help to increase buy-in for measures that require the active participation of citizens.

There is also a role for employers to play in supporting the health and wellbeing of their workforce. As working practices have shifted so much in recent years, so too should employers’ strategies for supporting workers, particularly those working in remote or hybrid working environments. This is especially important for women, who tend to be disproportionately affected by poor mental health in the workplace.

Many of the themes to come out of the roundtable discussion understandably align with Nuffield Health’s recommendations made in the report, which argues that the health and wellbeing of the population is our most important national asset, and should be a national priority.

Time to reprioritise rehabilitation

By Sara Hazzard

This historically under-funded service could be key to reducing pressure on acute NHS services, and pave the way for a healthier, happier workforce, writes Sara Hazzard, Assistant Director Strategic Communications and Co-Chair Community Rehabilitation Alliance at The Chartered Society of Physiotherapy (CSP).

Transformation doesn’t always need to be complicated, expensive or even that radical. Sometimes, it can be achieved by simply prioritising an existing, under-utilised asset. Rehabilitation services are a case in point and if the NHS is to have any hope of tackling some of its biggest challenges, it is exactly that kind of transformation that will be required.

At its best, rehab makes lives worth living. It adds life to years and years to life, enabling people to recover from major trauma or serious events like stroke and cancer, while supporting others to live with long-term conditions, such as COPD or arthritis. Rehab gives people the mobility and function to maintain independence and reduce the need for other NHS and social care services.

At its best, rehab keeps the NHS moving. It reduces the number of people being admitted to hospital by helping people to manage their conditions in the community.

This means greater system capacity for anyone who needs to arrive at the front door of a hospital, while inpatient rehab ensures they recover promptly and are ready for discharge, often to those much-needed community services, in a timely manner.

All of this allows for greater flow throughout the system, unblocking some of the most pressurised parts of the NHS.

Finally, at its best, rehab also yields benefits for wider society, reducing health inequities and sustaining a healthy, productive workforce by reducing sickness absence. Unfortunately, too many people do not find rehab at its best.

It has been under-funded for decades and shown a chronic lack of prioritisation, sometimes derided as a Cinderella service of lower importance than surgical treatment and medication. Historically, the problems were most significant in the community, with patients often discharged and then waiting weeks, if not months, to be picked up by outpatient services.

During the pandemic, however, hospital gyms and other spaces were lost to make way for overspill wards and to allow social distancing, making high-quality rehab harder to access for inpatients too. This has been further exacerbated by the most recent winter crisis when further rehab space was lost to create room for extra beds.

The irony of investing in beds rather than the rehab that could prevent so many needing one has not been lost on the profession. The impact of this loss of space is taking a toll on patients, staff and the system alike.

Six in ten physiotherapy staff in a recent survey said they are seeing increased levels of disability and 50 per cent report depression and anxiety among patients as they struggle to cope with long-term pain and immobility.

The survey also reveals that the issue is having a further impact on the NHS workforce crisis, with 32 per cent saying it means they struggled to recruit staff and four in ten citing retention problems. What is more, 60 per cent of respondents say they are considering quitting the profession altogether because of the issue.

The lack of rehab is also increasing the need for readmission to hospital and more intensive treatment, the survey shows. Clearly that situation cannot continue. Services need to be given the appropriate space, staff and resources to provide high-quality rehab.

That’s just the minimum required, however, to meet the enormous patient demand that has built up in recent years and continues to grow every month, according to NHS figures. To truly transform how we deliver healthcare in this country, we must break free of the outdated mode of thinking and place a far higher priority on the value of rehab.

That shift appears to be happening – and not a moment too soon. In a letter to the Community Rehabilitation Alliance, which the CSP co-chairs and convenes, Health Minister Will Quince said he agreed that “rehabilitation is as essential to good health outcomes as medicines and surgery”. With millions on waiting lists and large parts of the system falling down, rehab’s time has come.

Now’s the time to invest in rehabilitation and the workforce to deliver it, recognising the ripple effect these vital services have through the system. But this requires leadership, and it is vital that there are accountable leaders whose focus is on the effective commissioning and delivery of personalised rehab.There is much work to do, but this shift of emphasis could unleash the enormous potential of rehab and have a transformative impact on the NHS at a time when it’s needed most.

The Chartered Society of Physiotherapy will be joining ICJ and Public Policy Projects at the Integrated Care Delivery Forum in Leeds, on Wednesday 28 June. The event is free to attend for relevant healthcare professionals, so come and say hello!

“Time for health and care to face the right way” – Stephen Dorrell

By Stephen Dorrell

In his foreword to Public Policy Projects’ (PPP) latest ICS Delivery Forum report, Chair, Stephen Dorrell, argues that now is the moment to reorientate the health and care system and seize upon cross-party support for integrated care systems.

It is an old truth that our system of health and care services faces the wrong way. Success obviously requires the ability to respond in a timely way to demand for high quality care and treatment, but the objective should be to support people to enjoy healthy, happy years of life rather than simply to treat disease. Delivery of this objective is the focus of our work at Public Policy Projects.

To borrow a word chosen by Coventry and Warwickshire ICS Chair Danielle Oum, integrated care has the potential to ‘subvert’ our system of health and care. Resources and effort can finally be rebalanced to better target health prevention, early intervention and reducing health inequality.

This thought process underpins the development of ICSs; furthermore, it is a thought process which, crucially, is the subject of bipartisan support between the Labour and the Conservative Party.

“National government has created the structures and can coordinate their development, but it cannot micro-manage delivery.”

This is vital. As we go into the pre-election period, the framework of health policy for the next decade is not the subject of party-political debate. There will of course be intense arguments about the health service in the run-up to the election, focused in particular on funding levels which do represent a political choice, but the principle of integrated care is now a shared ambition across the political divide.

But, although the aspiration has been articulated many times, the ICS programme is still in its very early stages. Despite the predictable journalistic desire to declare the system “broken” and call for headline-grabbing “reforms”, it is important to remind ourselves that the current structure is only 12 months old.

The policy challenge centres on the development of properly integrated care systems at local level. National government has created the structures and can coordinate their development, but it cannot micro-manage delivery. Any attempt to do so is not only certain to fail; worse than that, attempts to over-centralise will ensure that valuable local initiatives will fail too.

This is not a prediction; it is a history lesson. The NHS has always struggled to create a healthy balance between local initiative and central accountability; the requirement to create more integrated local systems makes that balance more urgent and more difficult.

The ICS Delivery Forum is a series of events designed to address these challenges. Our focus is on developing ICSs and helping them to deliver integrated care for citizens and populations.

Our inaugural Delivery Forum convened leaders from across the West Midlands at the City Library of Birmingham. This centre for local excellence epitomises the ambition of integrated care – an anchor institution that creates space for creativity, employment and learning while bringing communities together and fostering close ties between public services and the public themselves.

We believe these events help create the space to allow ICSs to deliver on their promise. We also believe that the successful delivery of that promise is what will ensure that the NHS maintains the position it established 75 years ago as a global role model for universal healthcare.

The full version of the West Midlands ICS Delivery Forum Key Insights report can be found here.

Stephen Dorrell is Executive Chair of Public Policy Projects, and was a Member of Parliament from 1979 to 2015. He served as Secretary of State for Health from 1995 to 1997, and was Chair of the NHS Confederation from November 2015 until 2019.

Majority of public would use health tech to avoid hospital, research finds

By Integrated Care Journal

Survey highlights increasing public acceptance of healthcare technology to self-manage care and take greater individual responsibility for health.

The majority of people would use health technology if it meant they could avoid going into hospital, new research carried out by Ipsos on behalf of the NHS Confederation, supported by Google Health, shows.

The same proportion – more than 7 in 10 people (72 per cent) – would also use technology including wearable and health monitoring devices to help better manage and monitor their health and would also be willing to share the information and data gathered with their doctors and other medical professionals.

The survey of 1,037 members of the public highlights people’s increasing appetite for using technology to self-manage their care, and more broadly, to take greater responsibility for their health and that of their families.

Nearly 4 in 5 people (78 per cent) also said they would be happy to use different types of health monitoring equipment to help manage their health if an NHS professional recommended it to them, with nearly 9 in 10 (89 per cent) people aged over 75 willing to do so.

The results have also found that just over half (53 per cent) of the 92 people included in the survey who have been diagnosed with a long-term condition resulting in them interacting with the health service four or more times a year, are already using the NHS App to access personal health information, compared with one third (33 per cent) of the general population.

The government recently announced a target for patients at more than 90 per cent of general practices across the country to be able to use the app to see their records, book appointments and order repeat prescriptions by March 2024.

Commenting on the findings, Matthew Taylor, chief executive of the NHS Confederation said: “This research shows the potential of technology in empowering patients to better manage and monitor their own health, especially if it means they can avoid being admitted to hospital.

“There is clearly an appetite amongst the public to use technology to self-manage their long-term conditions, and more broadly, to take greater responsibility for their health and that of their families.

“The government’s recent commitment to accelerate and widen the use of the NHS App should also help to strengthen the public’s understanding of the benefits of digital engagement.

“However, the decisions we make now as a society will determine whether technological change means we can make continuous improvement in the offer we make to everyone through the NHS, or whether it will divide ever more widely the ‘healthy haves’ from the ‘unhealthy have nots’. We must always deliver greater digitisation with equity in mind.”

Elsewhere, the survey findings showed that just over 8 in 10 (83 per cent) adults already use some form of technology to manage their health, and this increases to nearly 9 in 10 (89 per cent) people living with one or more long-term condition. However, only just over half of those surveyed were currently satisfied with the technologies and tools available for them at present.

The research also showed that that nearly three-quarters (73 per cent) of patients want their doctors to provide them with the “best technology available”, with three-fifths (58 per cent) wishing “their doctor provided them with technology to monitor their health”.

Ease of appointment booking and the ability to communicate via messaging services with healthcare teams are also high on the list of priorities. The research also found that more than two thirds (68 per cent) of people believe that healthcare in the future will include more technology and less reliance on healthcare professionals, although this comes with the concern that without access to the right technologies, access to healthcare could be limited.

Susan Thomas, UK Director, Google Health added: “Google Health has been privileged to partner with NHS Confederation and Ipsos to drive this piece of research; the findings have resonated with our mission to help everyone, everywhere be healthier through products and services that connect and bring meaning to health information.”

The reality of the world: anticipating failures to achieve success

By Emil Bernal

Emil is a former British Army officer who now specialises in change and transformation in complex environments, including the NHS. He is currently Head of Transformational Programmes and Projects at NHS Shared Business Services.

I recently walked into my local high street bookshop. I counted dozens of books telling me how to succeed at project delivery. There was no shortage of people offering their tips for success. I couldn’t find any books about how to avoid failure.

This is odd but not surprising. From childhood, we’re conditioned to be uncomfortable with the thought of things going wrong. No-one likes making mistakes. Our education system is built on telling us ‘how to do things’, and punishes us for getting things wrong. The world is filled with motivational speakers talking about the sunny uplands. Can you think of a single modern motivational speaker who talks about avoiding the dark abyss?

Emil Bernal, Head of Transformational Programmes and Projects, NHS Shared Business Services

Programmes and projects are no different. We start with optimism and marvel at the promise of a brighter tomorrow. And, for sure, optimism is needed to motivate a team to take on challenging goal. But excessive optimism in our ability to shape and influence the future has led to spectacular failures.

Things can and do go wrong. The NHS has the dubious honour of hosting one of the most expensive failures – the world’s largest civil IT programme, the £12.4 billion National Programme for IT.

In their book, “How big things get done”, Bent Flyvbjerg and Dan Gardner researched the outcomes of over 16,000 projects in 136 countries. Their data shows that 92 per cent of projects overrun on time, cost or both. And cost overruns can be dramatic.

The average cost over-run for every Olympic Games since 1960 is 157 per cent. NASA’s James Webb Space Telescope was 450 per cent over budget. Scotland’s Parliament building was 978 per cent over budget.

The private sector doesn’t do any better. In 2000, Kmart launched two IT projects. Costs exploded, contributing to the company going bankrupt in 2002. Even families get it wrong: you only have to watch Grand Designs to see people’s home renovations go over budget and run late.

We need to learn what went well with previous projects. And we need to understand what went wrong – “how not to” repeat the same mistakes. So, when wide-ranging reports are published – like Patricia Hewitt’s recent review of Integrated Care Systems – I start, as many people do, by thinking “how are we going to get this done”? The next thought is perhaps less common. How do we avoid things going wrong?

Here, then, are five ways to stop things going wrong:

1. Go to the cinema. Or, rather, think about projects in the same way as the film industry: get the balance right between planning and delivery. There’s often a push to start “doing something”. This misses the point that planning is doing something. The film industry understands this, and gives film producers time to plan. During planning, costs are relatively low while film producers explore ideas, produce storyboards, and redraft scripts. Costs explode when production starts and Hollywood stars and crews are working. The work that producers put in upfront means that filming follows a well thought-through plan and avoids costly delays.

2. Find experience and expertise. Very few projects are genuinely unique. There will always be something that makes a project different from others. But, in many ways, your project will be “another one of those”. People who worked on “one of those” will have valuable experience and expertise. Find those people.

3. Listen to that experience. Having found your experts, listen to them even if – especially if – it’s something you don’t want to hear. Listen when they tell you that the project will cost more than the figure you have in mind. Listen when they tell you the project is likely to be more complex and take longer that you ideally wanted. Listen when they tell you about the issues and risks you’re likely to face. It’s better to be told a painful truth early, rather than push ahead in comfortable ignorance.

4. Ask four questions. There is a cultural tendency to shy away from disagreement. So, be explicit and ask for alternative views. As we start to form an outline solution to a problem, I’ll often ask four interrelated questions: what’s good about our solution that we should keep? What needs to be changed? What’s not needed? And – probably the hardest question to answer – what’s missing?

5. Get hindsight in advance. Lessons learnt – or after-action reviews – are standard practice. Flipping this on its head is a useful way of identifying where things could wrong. This approach was popularised by psychologist Gary Klein and Nobel laureate Daniel Kahneman and is often called a ‘pre-mortem’. It’s simple but powerful. Get the team to imagine that their project has already failed. What caused the failure? Work backwards to figure out the causes. Run through a few scenarios. The time spent visualising different outcomes will bring to life the future for the team. And, after the pre-mortem session, make sure that you re-energise the team’s belief in the project.

By taking these steps, you can give yourself the best chances for success. But even the best planning won’t stop issues from cropping up. A supplier lets you down. A team member falls ill. A pandemic. A ship getting stuck in the Suez canal. You’ll have to be ready to manage issues and find practical solutions. But, by getting the planning right, the window of time when risks can come crashing into your world will be smaller – like the film industry which spends time in planning so that the costly production phase can zip along from start to finish.

Learning from your mistakes is called experience. Learning from other people’s mistakes is called wisdom. I wonder how long it will be before I start to see the shelves of my local bookshop filling up with stories about things that went wrong and how to avoid making the same mistakes?